Purpose of the study: The cervicobrachial outlet syndrome is an anatomic and clinical entity related to intermittent or permanent compression of the brachial plexus trunks, and/or the subclavian artery and vein as they pass through six successive spaces in the thoracic cervicobrachial outlet, including the intercostoscalenic space. The purpose of this work was to evaluate the feasibility of endoscopic exploration of the infra-clavicular portion of the outlet and the options for therapeutic interscalenic release.

Material and methods: Cadaver study of 12 shoulders: 3 male, 3 female.

dissection of the supra and infra-clavicular region (n=3) to identify zones of potential impingement and determine the structures constituting the outlet;

Results: The medial and lateral clavicular approaches identified two zones of less risk considering the proximity of the neck vessels and the phrenic and suprascapular nerves. A first, it was difficult to localize the brachial plexus endoscopically. This was achieved after dissection and insertion of landmarks. Five endoscopic procedures had to be performed to localize the plexus and starte the interscalenic release. Minute identification of the entry points for the trocars, as a perfect orientation of the instruments was necessary to achieve the procedure. The control dissections did not identify any vessel or nerve injury.

Discussion: Few data in the literature examine the question of endoscopic interscalenic release. Unlike Krishnan and Pinzer, we found that endoscopic exploration of the outlet at possible, but difficult, procedure. Use of an arthropump remains to be evaluated because of the distension and impregnation of the tissues. Insufflations with CO2 might be an alternative.

Conclusion: To our knowledge, a supra-clavicular approach for endoscopic exploration of the brachial plexus has not been described. Exploration of the outlet via this approach might be a less invasive procedure than conventional surgery. Complementary research is necessary to evaluate the morbidity of the different techniques.

Purpose of the study: Classically, bone grafts are harvested from the iliac crests which can provide a limited volume of graft material. Using the reaming product might help spare iliac bone.

Material and method: A variable head RIA device (reaming, irrigation, aspiration) was used over the last year for ten patients who presented partial or segmental bone loss. The bone graft was constructed exclusively with the reaming produce following membrane induction using a cement scaffold. The tibia was reconstructed in nine cases and the humerus in one. Bone loss was 6 cm on average.

Results: The reconstruction healed in six cases within a mean delay of 6 months; the 4 other cases are under assessment. Complementary bone was necessary to achieve healing in one case. There were no complications involving the donor site excepting transient pain at the point of insertion.

Discussion: In this series associating an induced membrane and reaming produce, the time to healing appeared to be shorter than with cancellous iliac bone. The smaller size of the fragment may be a determining factor.

Conclusion: Reaming products collected from medullary cavities of the long bones can be used for reconstruction of bone loss.

Purpose of the study: Resection of a malignant primary tumour of the proximal humerus implies sacrifice of a large part of the humeral shaft and the periarticular muscles. Reconstruction can be difficult and raises the problem of preserving function. Recent work has demonstrated the pertinence of combining a glenohumeral prosthesis with an allograft. Several complications are nevertheless reported: non-union, allograft resorption, loosening. We report three cases of malignant primary tumours requiring wide resection of the humerus which were treated by reconstruction with a shoulder arthrodesis applying the induced membrane technique.

Material and methods: Three patients (mean age 15 years) presented a malignant primary tumour of the proximal humerus (Ewing sarcoma or osteosarcoma) which was locally extensive but not metastatic. Resection implied resection of 16 cm of the humerus (mean). The same procedure was used for the three patients: first phase: wide resection of the tumour and neighbouring soft tissues which removed the majority of the proximal end of the humerus and the glenohumeral joint, then insertion of a cement spacer; second phase: reconstruction with a shoulder arthrodesis using cancellous grafts positioned inside the induced membrane. Stabilisation was ensured by insertion of a non-vascularised fibula inside the membrane and with a plate fixation on the scapular spine.

Results: Mean follow-up is five years. There has been no local recurrence and no distant spread. The arthrodeses and the reconstructions healed without reoperation within six to eight months. The functional outcomes were not different from those obtained with shoulder arthrodesis with a mean elevation of 90°.

Discussion: There are many advantages of reconstruction with shoulder arthrodesis using the induced membrane technique: possible wide initial resection, more satisfactory carcinological resection, the periarticular muscles are not pertinent after arthrodesis; there is no need for prosthetic elements or an allograft exposing to later complications; the reconstruction time is a simple procedure; elevation remains satisfactory.

Conclusion: This technique should be included in the surgical armamentarium just like vascularised transfers, allografts and massive prostheses. The indication should be reserved for extensive resection.

Purpose: Wound defects management during or after a total knee arthroplasty is a challenging clinical situation which raises the risk of implant exposure and infection with subsequent removal and poor functional outcome. The clinical course of the tissue loss is unpredictable leading to retarded curative treatment.

Material and Methods: We report a consecutive retrospective series of 39 knee prostheses implanted from 1990 to 2007 where a wound defect occured during or after implantation of a total knee arthroplasty. Salvage surgery have included a flap with different way of treatment for the knee prosthesis. We studied time to onset of tissue loss, wound border vitality, presence or absence of implant exposure, type of cover flap distinguishing faciocutaneous and muscle flaps, retention or not of the implant, and time of secondary reconstruction.

Results: In 34 of the 39 prostheses, the implant use of the cover flap enabled saving the implant and proper wound healing. In 2 additional cases, wound closure using a flap enabled a reimplantation of a knee prosthesis. The joint remained functional but only 20 knees recovered flexion greater than 90°. In three cases, the implant had to be removed and a knee arthrodesis was done, in all cases due to infection with resistant bacteria (staphylococcus, serratia). Prognositic factors identified included: time from tissue loss to its treatment, usefulness of a cover flap to save the implant, or usefulness of two-procedure reconstruction in case of implant infection.

Discussion: We compared our therapeutic methods with the propositions in the Laing classification and preferred to distinguish a simplified three-step tactic based on time of exposure for determining the theraputic strategy for cutaneous tissue loss in knee prosthesis patients.

Purpose of the study: Osteitis with loss of distal soft tissue on the medial aspect of the leg raises a problem of cutanous cover, particularly in the event of longitudinal injury. Free flaps are frequently used with variable success in older patients with more risk factors. Four our more frail patients, we have used a retrograde soleus flap pediculated on the posterior tibial artery. We present here the possibilities offered by this flap and assess the different indications.

Material and methods: Six patients, mean age 55 years (range 44–68 years) were treated for cutaneous tissue loss measuring 9.5 x 6.5 cm on average. One patient was diabetic and two were smokers. The decision to use the soleus flap was made because of the presence of cutaneous lesions on the leg contraindicating a local falp. Arteriography revealed the persistence of the three vascular routes with satisfactory distal anastomoses, allowing high ligature of the posterior tibial arery intraopeartiely after a clamprepermeabilization test. The soleus flap was modeled to size and rotated en bloc with the tibial artery which was released to the retromaleolar localization for the distal flap^s. Treatment of osteitis incluced resection, cement filling and antibiotics then bone graft.

Results: All flaps survived. One had to be revised because of partial necrosis. There were no distal vascular problems. At minimum follow-up of 18 months, all the cases of osteitis had healed.

Discussion: The soleus flap pediculated on the posterior tibial artery is a reliable and effective flap. The territory covered can be very distal, reaching the foot. The vascularization of the soleus muscle allows moving the entire muscle, providing a very powerful flap. Deliberate sacrifice of a vascular supply considered as dominant for the leg is certainly a difficult decision, but which must be weighed against the risk of failure of a free flap.

Purpose: The diversity of treatments proposed for septic nonunion of the femur demonstrates the lack of consensus. Treatment modalities validated for the leg appear to be transposable to the femur. The purpose of this work was to compare different treatments used in our centre and identify optimal management practices.

Material and methods: We report a retrospective series of eleven patients (nine men and two women) who developed septic nonunion of the femur subsequent to trauma (n=9) or tumour (n=2). Sepsis developed early in seven cases and late in four. Mean time to treatment was 34.8 months. We based our strategy on a succession of steps starting with cure of the soft tissue and bone infection, before attempting reconstruction and consolidation.The first step involved fixation, antibiotic therapy and interposition of an acrylic spacer. The second step involved bone reconstruction, removal of the spacer, vascularised fibular graft associated with a cancellous bone graft (n=4) or massive cancellous graft inserted into the pseudomembrane created by the spacer (n=7).

Results: Mean time to resolution of the infection was 10.9 months. Cure could not be achieved in three patients. Bone continuity was achieved in 8.8 months on average. The time to bone healing (i.e. duration of external fixation) was 22 months. Refracture occurred in four patients. Consolidation was not achieved in two patients.

Discussion: During the second step, we preferred massive cancellous bone reconstruction due to easier technique, shorter healing time, and better adaptation of the reconstruction volume. Optimal time for the first step is about six months in order to avoid recurrent infection. Our healing times are similar to those reported by others: the healing index (time to healing divided by gap length) was close to that obtained with the compression-distraction technique. Refractures related to specific mechanical problems inherent in the femur lead to longer time for external fixation, minimum 13 months.

Purpose: Trapezometacarpal osteoarthritis is frequent in women aged over 50 years. Surgical cure may be needed after failure of well conducted medical treatment. When the trapezeal bone stock is insufficient for implantation of a total prosthesis, total trapezectomy can relieve the pain. This procedure is generally associated with stabilization ligamentoplasty of the first ray. The purpose of this study was to demonstrate the feasibility of this procedure using an arthroscopic approach and to detail the technique and its limitations.

Material and methods: This study was conducted on twelve cadaver specimens from eleven women and one man, mean age 85 years. Radiographs were obtained to confirm the trapezometacarpal osteoarthritis. Standard arthroscopic material used for the wrist was employed (2.4 mm optic, mini-shaver). Two portals on either side of the abductor pollicis lungus tendon were used to approach the trapezometacarpal joint. Total trapezectomy was performed with the mini-shaver distal to proximal. A tendon band measuring 6 to 7 cm was fashioned from the abductor pollicis longus tendon via a proximal contraincision. This band inserted on the first metacarpal was passed through two bone tunnels bored in the base of the first and second metacarpals then fixed to the base of the second metacarpal. Operative time was noted. The quality of the bone resection was determined on postoperative radiographs and open inspection.

Results: Arthroscopic total trapezectomy with stabilisation ligamentoplasty was achieved in all cases and evaluated radiographically and at open inspection. No lesions to noble elements were observed.

Discussion: This minimally invasive technique for trapezectomy associated with stabilisation ligamentoplasty was found to be feasible but did require a certain degree of learning. We were unable to identify any procedure-related morbidity, particularly concerning the sensorial branch of the radial nerve to the thumb.

Conclusion: The results of this preliminary study are encouraging and suggest a clinical trial should be conducted to prove the advantages of this technique in terms of morbidity and socioeconomical cost.

Purpose: Instability of the injured elbow early after repair can lead to recurrent dislocation or failed fixation. Complementary immobilisation increases the risk of stiffness. The purpose of this study was to assess the contribution of dynamic external fixation which allows protected mobilisation and controlled distraction. We wanted to determine feasibility and appropriate indications.

Material and methods: We used the Pennig articulated elbow fixator in twelve trauma victims. Most had complex injuries: five dislocations with lesions of the medial ligaments and fractures of the radial head, including two with early recurrent dislocation; five joint fractures (involving to various degrees the lateral condyle, the head of the radius, the olecranon, and the humeral surface). This fixation method was also used for old or sequelar lesions to achieve reconstruction of the humeral surface (n=3) or after extensive arthrolysis (n=2). Mobilisation was started on day five postop.

Results: For the fresh injuries, the humero-ulnar articulation was centred in all cases. In these patients, mean final flexion was 0.35.130° and pronation-supination was 0.10.155°. One purely lateral dislocation was observed. Radio-ulnar synostosis after fracture of the ulna (n=1) and osteoma (n=1) were also observed.

Discussion: This dynamic external fixation system is a simple and safe procedure if a rigorous technique is applied. This method enabled early rehabilitation without secondary displacement and also enabled reliable contention particularly important in these multiple injury patients. The patients experienced very little pain during rehabilitation exercises, probably due to the distraction which did not appear to provoke reflex dystrophy. For complex instability of the elbow, the reduction of stress forces during mobilisation movements enables an extension of the indications for preservation of the joint fragments. Less reliable results are obtained for stiff elbows with old lesions.

Purpose: Bone quality in elderly patients always subject to osteoporosis can compromise the stability of osteosynthesis materials. The fixation can be reinforced by using acrylic cement, allowing early rehabilitation. The purpose of the present work was to investigate the quality of acrylic cement-reinforced osteosyntheses and to study the functional consequences of this method. We also analysed early or secondary complications and determined the mid- and long-term advantages and disadvantages for the patient’s quality of life and also for later interventions on the fracture site.

Material and methods: Forty female patients treated between 1990 and 2000 were studied retrospectively. These elderly women (mean age 86.2 years at fracture), had 44 fractures (38 femurs including two with double fractures; four humeri) which had been treated by acrylic cement reinforced ostheosynthesis. The physiological status of the patients before trauma was assessed with the Robinson score and the degree of osteoporosis with the Sinon index. The quality of the cementing was assessed using the Cameron technique. Minimum follow-up was six months, necessary for inclusion.

Results: The preoperative Robinson score was 18.8. The mean Singh index was four. Cementing was satisfactory for 29 fractures. Immediate weight bearing or complete use of the limb was possible early for 42 of the 44 fractures. Bone healing was achieved at a mean 2.8 months for 43 fractures. Mean follow-up was 9.8 months. Twelve patients died before the end of the first postoperative year. At last follow-up, there was one nonunion and five infections, including three bone infections. The Robinson score at last follow-up was 16 on the average. Subsequent interventions did not have to be modified or abandoned because of the acrylic cement reinforcement of the osteosynthesis.

Discussion: The results of this retrospective series are comparable with those obtained with other centromedullary nailing or primary or secondary bone grafting techniques used for the treatment of patients with severe osteoporosis.

Purpose: Reconstruction of massive bone loss with cancellous bone deposited in a pseudomembrane induced by a cemented strut was performed in 40 procedures. We evaluated the 5-year results of this technique for the treatment of gaps measuring more than 5 cm.

Material and methods: We reviewed 12 patients; all had suffered major loss of tibial bone. The operations consisted in resection, insertion of a cement strut, and closure with a local are free flap over he disinfected soft tissues. The second operation at least two years later used a fragmented autologous cancellous graft leaving the membrane intact. The fibula was used as a tutor whenever possible. Bone losses measured 5 to 25 cm in young men who had infection after trauma or, in one patient, tumour resection. We analysed clinical and radiological outcome.

Results: All patients were seen five to ten years after initial management. At last follow-up, all wounds had dried and bone healing was solid. All had required secondary repeated grafts, realignment surgery (for valgus and varus) or operations related to the initial injury (arthrodesis, claw toe). Generally, the patients had resumed their occupational and recreational activities. The walking distance was not limited and single leg stance was painless. The radiological analysis demonstrated a trend towards graft tubulisation.

Discussion: The stut technique using cement induces the formation of a pseudo-synovial membrane. This technique has been used for more than ten years in our unit to treat circumferential defects. Bone healing was achieved in all patients. The main complication was valgus malalignment which almost always requires surgical correction. Rapid healing is not a function of the extent of the gap but rather the radical nature of the resection and the quality of the cover. This technique should be compared with other alternatives used to fill major bone gaps (Illizarov, vascularised bone transfer).

Purpose: Loss of cutaneous tissue during knee prosthesis procedures raises the risk of implant exposure and infection with subsequent removal and poor functional outcome. The clinical course of the tissue loss is unpredictable leading to retarded curative treatment.

Material and methods: We report a consecutive retrospective series of 39 knee prostheses implanted from 1990 to 2000 where cutaneous tissue loss was covered with a flap. We studied time to onset of tissue loss, wound border vitality, presence or absence of implant exposure, type of cover flap distinguishing faciocutaneous and muscle flaps, retention or not of the implant, and time of secondary reconstruction.

Results: In 38 of the 39 prostheses, the implant use of the cover flap enabled saving the implant and proper wound healing. The joint remained functional but only 18 knees recovered flexion greater than 90°. In one case, the implant had to be removed due to infection with resistant Serratia. Prognositic factors identified included: time from tissue loss to its treatment, usefulness of a cover flap to save the implant, or usefulness of two-procedure reconstruction in case of implant infection.

Discussion: We compared our therapeutic methods with the propositions in the Laing classification and preferred to distinguish a simplified three-step tactic based on time of exposure for determining the theraputic strategy for cutaneous tissue loss in knee prosthesis patients.

Purpose: Post-traumatic instability of the elbow is defined as a subluxation of the humeroulnar joint at least three weeks after trauma. Treatment is based on restitution of the three elements essential for stability: the coronoid process, the height of the head of the radius, repair of the lateral ligaments. The purpose of this study was to analyse treatment modalities for these unstable elbows and assess mid-term results.

Material and methods: This consecutive series included all patients who underwent surgery between 1992 and 2000. There were 22 patients (twelve men and ten women, mean age, 46 years, age range 26–74 years). The left elbow was involved in 16 cases (two dominant) and the right elbow in six cases (six dominant). The initial trauma was isolated dislocation in six patients, dislocation with fracture of the coronoid process and the head of the radius in nine, trans-olecranon fracture-dislocation in seven. Mean time from trauma to revision for instability was four months. A dynamic external fixator was used for stabilisation in all cases, with or without restoration of the height of the radius with a radial head prosthesis (n=12), and reconstruction of the coronoid process (n=7). Reinsertion of the lateral ligaments was necessary in 17 patients.

Results: Mean follow-up was 33 months. Six patients required a second procedure for transposition of the ulnar nerve in three and arthrolysis of the elbow joint in three. There was one failure requiring total elbow arthroplasty less than one year after revision. At last follow-up, outcome according to the Mayo Clinic classification was excellent in ten patients, good in five, fair in one, and poor in five (four trans-olecranon fracture-dislocations). Twenty patients had a stable elbow. Mean flexion-extension was 113° with a 19° mean extension deficit. At last follow-up, six patients had radiographic signs of osteoarthritis.

Discussion and conclusion: The results were directly correlated with the nature of the initial trauma and the quality of the restoration of he stabilising elements. The poorest results were observed after trans-olecranon fracture-dislocation, which led to osteoarthritic degradation in three out of four cases. In our experience, treatment of sequelae of elbow dislocation, or the terrible triade, can give satisfactory results with an appropriate treatment strategy.

Purpose: Demonstrate the importance of surgical repair of soft tissue damage in an orthopaedic surgery unit.

Material and methods: This retrospective study included 455 patients who underwent soft tissue flap surgery between April 1980 and April 2000. There were a total of 556 flaps, hand and finger flaps were excluded from the analysis. Overall results concerning the general treatment for the underlying conditions was not analysed. There were 132 women and 313 men, mean age 42 years. Among these patients 276 (60%) were referred from other hospitals for secondary care. Most of the tissue damage (373 patients among the 455) concerned the lower limb. The soft tissue loss was part of a bone and joint problem in most cases, including: septic nonunion and osteitis (189 patients), trauma and complications after planned orthopaedic surgery (74 patients), grade IIB or IIIC open fractures according to the Gustilo classification (66 patients). There were a total of 485 pediculated or fasciocutaneous muscle flaps and 71 free flaps.

Results: Flap survival rate was 90.32%. The result was total necrosis of the flap in 9.68%. The rate of failure was 30% for free flaps and 5% for pediculated flaps.

Discussion: This study demonstrated the usefulness of surgical care of soft tissue damage in an orthopaedic surgery unit, particularly for trauma and infection patients. The large number of pediculated flaps is an expression of the reliability of this technique easily applied in a polyvalent orthopaedics traumatology unit. The high rate of failure for free flaps is related to the inherent risk of secondary repair and the inflammatory or infected nature of the soft tissues and also the difficulty encountered in controlling this type of surgery under such conditions. The data reported here allow individual analysis by type of pathology.

Conclusion: Overall management of bone and joint disease patients requires proper skill in soft tissue repair.